S 2355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING-ELECTRICAL PERMIT No.
BUILDING DIVISION APPLICATIONIPERMIT PLUnmING-MECHANICAL S 2355
ItUILDING PRO]ECI'IDRNTIF'ICATION
BUILDING,ADDRESS: SANITARY Nf1. APPLICA'HONSUBMI'1TALDATE
Y
OW E S NAME! 1.11ONL: CONTRACTOR'S NAME: LIC NO,
N/C C(In OL,p
AHC ITE INGINBER: LIC NO. ADDRESS: ❑
CONTACT, rlioNc: BUILDING PERMIT INFO
i (` _7E) ❑ Consultant Fees Paid by Applicant(Initial) B� ELL❑'CI' PLUMB MECCH
LICENSED CONTRACTORS DECLARATION QTY ELECPRIC PERMIT FEE
1 hereby affirm that I are licensed under provisiens of chapter 9(commandvg JOB DESCRIPTION
Dat with San, aAlO(BuOHvi ....3oftne Business and rroreauions code,met my flans,is RESIDENTIAL:
FOO 'n full force std PERMIT ISSUANCE
ax_1 ' 6- 'L ❑SPDWL C3 KITCHEN RI-1.10U1i1.
QUZU Licenu CP xs LIc.M— APPLIANCES-RESIDEN9'IAI. ❑ADDI'DON '�j�'LUMBING RE-PIPE
NQL Dule Ciarlocter PRAIA) yfff7w_
ARCHITECTS DECLARATIONPANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p H Z 1 undm
o od my plans shell heated as public records MODIFICATION
O Z'4 UP'102N)AMPS [-I INTERIOR ❑CHIMNEY REPAIR
F. W licensed Professional 201.1000AMBS IMPROVEMENT I]SWIMMING POOLS
ayf; OWNER-BUILDER DECLARATION OVER ln(NIAMPS C3 BATH HF.MOUEVREPAIR C1 DEMOLITION
sC Q I hemby affirm that 1 am airman from the Comracmr'a Liccme Law for the
E U I'olluwing reason.(Section 7031.5,Business onJ Professions Coder Any city or county SIGNS ELECTRICAL. ❑OTHI!R
I+)3
LLy which requires a permit to construct,alter,improve,demolish,or repair any stmnuu
prior to its issuance,also requires the applicant for uch perminn file a signed statement SPECIAL CIRCUIT/MI SC.
99 y thou he is licensed pursuantmm the prnaidmte of the Cennacan,Liceree Law Charter
^p0 (commencing with Section TAX) Division 3 of the Businessand Professions Code)an TE MP.METER OR POLE INS r. COMMERCIAL:
It.lY 0% that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^+W
Scatter 7031.5 by any applicant fora pe,aaa mbicps the applicant too civil penalty of POWER DEVICES
r� not mor,than Five hundred dollars OCRX0. ❑TENANT El FOOD SERVICE
Z Y IMPROVEMENT
Q ❑hanhe sork.ital ropcny,sn myemntended m otheredfou theirsnle 044,Ih union SWIMMING POO1.CI[17 RIC
will dalhcwon,andth The
ncloti mended mothered fmmla,,Iy ,,44,nnsloess - ❑OTIIIiR
�^m
u]3^ pec Profusions Code The Ccs numeral.
Llemua Luosecs wapplyisanowner of OVfLH'IS-SWITCIii!S-FIX'I'tlitB6
2 his...who builds nr improves thereon,and who m nts such work intended
ar carmf reougM1
his own employeese provided that such improvements hi nut iyea"d a otTeud for NEW RESIDENTIAL IH.E(2'R SQ Fr.
cmile ,howee Bh:,nildin burin of proving
issoldid noneild or completion,the �p.17.FLOOR AHPA SQ,FE
owner-builder will hove the harden of proving thou he did urn build or in:prnve for pa,
xv oftufa).
1,as owner of the progeny,am exclusively contracting with licensed contntcmts to TOTAL:
cvnstruet tIm,micet(Sec 1044,Business and Pn leaioro Code:)Thin Contmcror'I Li- -
wseLaw does not apply tounowner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
ho onntrens for such projects with s comractort lirensed p irxuantio the Comiscou"
Licence Lues. PERMIT ISSt1ANCE
❑I am exempt under Sec.
It&I'C Iia this reason
Dweer nate Al THR-DRAIN&VENT-WAT RR(EAI VALUATION
Won NEWS CObiofNSAT[ON DECLA ION PACK FLOW IRol'EC'T.DF:VICIi
1 hereby ill ai under penalty of perjury one of the following do rkeris nu
❑(have and will maintain. Consent to Labor Code,for the Workers Counter- UNAINS-FLOOR.H(N)R AREA,GOND. STORIES TYPE CONSTRUCTION
ration, r Presided for ri Suction 3700of the Labor Coda,for the perfnrmmrco nl"the
work have and
will
laintii is issued 1§X'fUkBS-I'ER'TNAI'
I havc:md will maintain Workers Crnnpe fit
v Insurance,which
as reyuired by Smtinn
3]INl of the labor CnJe,fnnheperfor ane (the work fur which this permit is issued. GAS-GA.SYSTF.h1.1 INCA DITfLLTS I OCC.GROUP AIN
My Worko' tytlba nom tar' puticy t t
4 Curzier:�/ /y(_ t yNOMWORK� � GAS-EA.SYSTEM OVF.R4(I!A)
CEH (PIC OMPE SATIO ON INSURANCE
WORKERS'
COMPENSATION INSUkANCI3 GRIiASrIINDI15TH1.WASTE INTERCEPTOR
in los)Ohisscedon Deed not hcomplctadifthe pcmlh is fonmeM1mWrcd Jollam l$I00f GREASFTRAP NCH
(cenify that in the pertarmance of the work for which this permit in issucd,l shall SI!W ER-SANITARY-STORM 1: 2(111 Irl'.
not employnny peman in onyamnnerso nc to beconsc ubjecd m the Wnrkit Conlpml- 1' ERGY FEE
Z ,z, cation Laws of California.Date WATER HEATER WNFNT/ELFCTR
Q Applicant J�AIUUzj' 141998
rq
NOTICE'IY)APPLICANT.IL a icr ia.Gag this Can;^cmc of Hat n,you should WA'I'PH SYS'I'HMO RI!AI'1NG SOILS PIT
ai !^ became subjed to the Worker's Com,monion provl s of the Laber Code,yon most
fJ.l forthwith comply with such provisions at this permit shall he deemW revoked. WXI ER SERVICE
UO Cat the RUM ION LENDING AGENCY NEW kE51D1!NTIAI.I'LMN, SQ PE 1 c
1 hereby which
mule Werc is sued(See.3 lending agency for the Performance of
the work for which this permit is issue)(Sec.lfn],Civ.Cd
LI-t H TOTAL:
Lenders Nantc
r j
LUS1 LclWers Address T L:
0. 1 cenify that L have read this application and state that the ahwe information is BUILDINGFEE
FTA c..nem.l agree to comply with all cityand countyeainancesend stain lawsrdming In QTY, MECHANICAL PERMIT FEL?
Uz buddin,neormdion,and henhyarl, ire nalaawnenivesof thNnity tont
eernlwn the SEISMIC FEE
above-mentiuned pro art,for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hannle.0 the City of Cupertino against ELECTRIC FC
Ilabiliues,judgmams,ensts andcxpense Lich may In any wayaucma against said City pUl'ER OR AOD'H]MECH.
in cons a ace of the granting of this cmlit. PLUMBING
APP1 CA T UNDERSTANDS D WILL COMPLY WITH At.1.NON-POINT ALR HANDLING UNIP(1'U Ig01X)CEM)
SOI't B iCOLA'TIONS. MECHANICAL(il!
AIR HANDLING UNIT(OVER IBdaq CFM) CONSTRUCT] rAX
.'grailfft.77,applictiout ommmor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGA'ON FEE
HA'LARDOUS MATERIALS DISCLOSURE
Will the applicamorfurore building uecupmn.moreorh:mdle hazu.items mmmim 11I7A1'ING UNIT(To I adgiI BI'U)
as defined by the Cupertino Municipal Cale.China,9.12,and the Health and Safety
Code,Seetinn 25532(al] IIEAIING UNIT(OVER BX)INXI BTU)
❑Yeas ❑No YEN'IRATION PAN is INGLE RIS1D) PAID
Date Rcccipt M
Will the applicant it future building by he Bl use .,Ar equipment of devices which
emit hazardous air mintuminunta as definnl by the)fay Area Air Quality Menage'nem BOILER-COM PMil POR 1(NI,INXI Ii'fU) T
LDiona,l ❑No BOILER-COM P(OVER 100,000 BTU)
AIR CONDI'I"IONER rwA thea haranlons materials rcquirenunta under Chapter f95 o[the Cnli- ISSUANCE DATIi&Safety Code.Sections 25505,25533 and!25534,1 undcrsmnd that if the NEW RESIDENTIAL MECH. SQ.FT. .e1�-//q non cumeadif,11wavrandV C.(�mm�tr wlthorized agent Date TOTAL: ISSUED BV:
OFFICE